Category Archives: Technology

New Tech: Augmented Reality In The OR?

Virtual reality headsets have been all the rage for some time. They immerse the wearer in a complete virtual world, and are typically used for gaming. Augmented reality, on the other hand, overlays virtual items on the real world so both are visible at the same time. Think the notorious Pokemon Go app:

What if this technology could be used for medical purposes? You could overlay diagnostic or anatomic information on your patient to help guide therapy, surgery, etc.

A group at the University of Alberta in Canada have been playing with this technology. ProjectDR takes any kind of image-related information and projects it directly on a patient.The patient is first scanned using surface markers like they do when making movies:

Obviously, no fancy suit or huge number of markers is needed. Once this is accomplished, the diagnostic information can be projected onto the patient. The patient can move, and the projector will compensate and keep the projection anatomically correct.

Here is a short video that demonstrates the system:

So is this useful? Unfortunately, not yet. It may eventually be good for office-based trauma professionals, but it needs further refinement. This version uses an actual digital projector, which means it will be subject to shadows which will interfere with viewing, especially if a surgeon gets his or her big head in the way.

Here’s how it will really have to work: The system could function quite well in surgical procedures. Imagine the surgeon being able to don a VR headset (lightweight, please!) and see the surgical field with key information overlaid on the display. Or even easier, incorporate it in the DaVinci robotic system display. Add vital signs in the upper corner and details of anatomic structures that have not been surgically exposed yet. It could help show anatomic anomalies in great detail, such as vascular variants. And heck, why not throw in some on-demand magnification as well?

As with most new and exciting tech that hits the general media, a version that is actually usable by clinicians is several years away. But it should be fun when it finally gets here!

Reference: University of Alberta ProjectDR system

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Best Of AAST #10: The Hybrid ER Room?

The next abstract is an interesting demonstration of the use of technology is trauma resuscitation. Pretty much all technology imaginable. It details the use of a “hybrid ER” room, which combines resuscitation space with all sorts of imaging and even interventional angiographic procedures. Here’s an image of the room when it was first written about in 2012.

A = CT scanner   B = CT exam table   C = movable C-arm   D = monitor screen   E = ultrasound   F = ventilator

This setup was installed at Osaka General Medical Center in Japan nearly 10 years ago. The authors have written occasional papers about it, and have now performed a study on its impact on trauma patient survival. They studied major trauma patients during two time periods. The first was pre-installation (2007-2011), and the second started immediately after installation (2011-2020). They specifically looked at 28-day mortality, and tried to tease out the relation to injury severity.

Here are the factoids:

  • About a thousand patients were studied, 348 in the pre (conventional) group and 702 in the post (hybrid) group
  • 28-day mortality was significantly lower in the hybrid group
  • Using a fancy statistical test (cubic spline analysis), they showed that 28-day mortality sharply decreased 200 days after installation of the hybrid ER
  • Mortality decreased disproportionately more in the hybrid ER as the injury severity score (ISS) increased

The authors concluded that the hybrid ER may have improved survival, especially in the more severely injured patients.

Here are my comments: Hmm. This is an association study that only looks at one variable, the new hybrid ER room. How many other variables may have a potential impact on survival? And how have those variables changed over the past 11 years? I worry that the study premise is too simplistic, but it certainly makes this unique resource look good.

Here are some questions for the presenter and authors:

  • How did you select your patients? You describe about 1,000 patients over 11 years, which is only about 100 per year. What about all the others?
  • What is it about the hybrid room that you think confers such a survival benefit to your patients? It seems to work for all patients, blunt or penetrating, badly hurt or not. What’s the magic?
  • Do you see the same effect for patients who were treated at other hospitals first and then transferred? The extra time that passed could decrease survival in severely injured patients.
  • Please explain cubic spline analysis clearly. I always worry when super-fancy statistical tests are needed to detect a difference. Why was it needed in this case?
  • Why did it take 200 days to see an effect from the installation of the hybrid ER? What happened at that point in time?
  • Please explain how the actual survival is so much better than predicted for ISS=75 patients. Your graph shows an actual survival of about 22%, as opposed to the 3% in your conventional ER. That is a massive improvement! How do you do it?

As you can see, I’m a bit uncertain about how this works and how the lessons can be applied to other centers. This is a unique resource, and the rest of the world needs to know a lot more about it before deciding to try it out themselves.

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The Newest Flavor Of 3D Printing

I’m fascinated with 3D printing, and have written a number of posts on the topic. There are numerous applications in medicine, and particularly in trauma care. We are currently able to print substitutes for bone, cartilage (trachea), bladder, skin, and more. To date, all of these use the same 2D technology found in ink-jet printers. But instead of 2D splashes of ink, three dimensional bits of plastic or metal are stacked on top of each other one layer at a time and fused by a laser.

UC Berkeley and Lawrence Livermore National Laboratory have developed a new 3D printing technology that coalesces an entire object at once using 3D information projected by shining light fro a standard LED projector into a column containing a special resin. The device has been renamed the “replicator” since it functions like the device seen in various Star Trek series. Here’s a brief video:

Bottom line: This is new technology, so it’s still a bit glitchy. The surface definition is lower than conventional 3D printing, which will limit its usefulness in some medical applications. And currently, the size limit is only four inches. But it will allow printing over existing objects, which may give it some real advantages. I’m sure there’s more to come with this promising new technology.

Related posts:

 

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Best of AAST #7: What’s New With Reboa

Despite all you read about it these days, REBOA is still very new. The first papers describing use in humans are barely 5 years old! A few select centers have been early adopters and are publishing a regular flow of research on their experience.

But we need more numbers! Many trauma centers have considered, or actually adopted the use of REBOA already. However, we are still working out a lot of the nuts and bolts of this very invasive procedure. The group at University of Arizona – Tucson reviewed the national experience over a two year period by massaging the data in the Trauma Quality Improvement Program (TQIP) database. All Level I-III trauma centers in the US are required to report their experience to this large, detailed collection of trauma data.

They performed a retrospective review of REBOA vs non-REBOA patients matched for demographics, prehospital and emergency department vital signs, mechanism of injury, degree of pelvic disruption in pelvic fracture patients, solid organ injuries, and lower extremity fractures and vascular injuries. The studied outcomes were complications and mortality.

Here are the factoids:

  • Nearly 600,000 records were scanned for the two year period, and only 140 REBOA patients were identified (!)
  • These 140 REBOA patients were matched with 280 similar non-REBOA patients
  • Average age was 44 and average ISS was 29, 74% were males and 92% were blunt trauma
  • Overall complication rate was 7.4% and mortality was 25%
  • There was no difference in 4-hour or 24-hour numbers of blood, plasma, or platelets transfused
  • ICU and hospital length of stay were identical
  • 24-hour mortality in the REBOA group was significantly higher (36% vs 19%)
  • REBOA patients were significantly more likely to require amputation (5% vs 1%)

Bottom line: These are not great numbers for REBOA! What gives? There are a number of possibilities:

  • It’s a database study, so some key information might be missing
  • The numbers remain small, only 140 patients out of half a million records in two years!
  • There is no way to know how the patients were selected for REBOA
  • The experience and skill level at the hospital performing the procedure is not known
  • The interplay of other injuries and comorbidities is unclear
  • And many more…

BUT, the numbers are concerning. The early adopter centers have better outcomes, and this has prompted many centers with fewer eligible patients to jump on the bandwagon. We all need to remember that this is a brand new procedure and we are still learning the nuances. It is extremely important that every center performing REBOA contribute their results to a national registry. We still need to figure out which patients will benefit from it, how it should be used, and how we can minimize complications and maximize survival in our patients.

Reference: Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma. Session I Paper 5, AAST 2018.

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Electronic Trauma Flow Sheet – The Video!

I’ve written a lot about the downside of the electronic trauma flow sheet. Well, a picture (or video in this case) is worth a thousand words!

I found a nice video on YouTube in which a nurse demonstrates some of the basic features of the Epic Trauma Narrator. As you watch, pay particular attention about the need for significant back and forth between mouse and keyboard, and the amount of scrolling necessary to get to all the various fields that need to be completed.

And keep an eye on the time. Now granted, the speaker has to slow down a bit to explain things. But if you look at how little gets entered in 8 minutes, you’ll get my point!

For those of you out there who have already adopted an electronic product, or are thinking about it, please leave comments here or Tweet your comments/questions!

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